PIAO, QINGAI.note¶
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Dear Sir.docx12.96KB
Personal, Address, Phone, and Passport/Travel Doc
ument Information
Name Provided: PIAO, QINGAI
Full Name in Native Language: 朴庆爱
Other Names Used: NO
Telecode Name Used: YES
Telecode Name 2613, 1987 1947
Sex: FEMALE
Marital Status: WIDOWED
Date of Birth: 11 SEPTEMBER 1933
Place of Birth: GANGWON-DO, KOREA,
REPUBLIC OF (SOUTH)
Country/Region of Origin (Nationality): CHINA
Do you hold or have you held any nationality other than the one
indicated above on nationality? NO
National Identification Number: 220523193309113027
U.S. Social Security Number: DOES NOT APPLY
U.S. Taxpayer ID Number: DOES NOT APPLY
Home Address: 23-150-4A WUYIHUAYUAN
TONGZHOU
City: BEIJING
State/Province: DOES NOT APPLY
Postal Zone/ZIP Code: DOES NOT APPLY
Country/Region: CHINA
Same Mailing Address? YES
Primary Phone Number: 18612039763
Secondary Phone Number: DOES NOT APPLY
Work Phone Number: DOES NOT APPLY
Email Address: hhy@agilent.com
Passport/Travel Document Type: REGULAR
Passport/Travel Document Number: G50682272
Passport Book Number: DOES NOT APPLY
Country/Authority that Issued Passport/Travel Document: CHINA
City Where Issued: SEOUL
Country/Region Where Issued:KOREA, REPUBLIC OF
(SOUTH)
Issuance Date: 04 MAY 2011
Expiration Date: 03 MAY 2021
Have you ever lost a passport or had one stolen? NO
Travel Information
The List of Purposes of Trip to the U.S.
Purpose of Trip to the U.S. (1):TEMP. BUSINESS PLEASURE
VISITOR (B)
Specify: TOURISM/MEDICAL
TREATMENT (B2)
Have you made specific travel plans? NO
Intended Date of Arrival: 06 MARCH 2016
Intended Length of Stay in U.S.: 6 MONTH(S)
Address where you will stay in the U.S.: 503 W GARDEN OF THE
GODS RD
City, State, Postal/Zip Code:COLORADO SPRINGS,
COLORADO 80907
Person/Entity Paying for Your Trip: OTHER PERSON
Person Paying for Your Trip: HUANG , HAIYUAN
Telephone Number: 18612039763
Email Address: HHY@AGILENT.COM
Relationship to You: OTHER RELATIVE
Is the address of the party paying for your trip the same as your
Home or Mailing Address? YES
Are there other persons traveling with you? YES
Are you traveling as part of a group or organization?NO
Persons Traveling with You:
Name (1): HUANG, HAIYUAN
Relationship to You: OTHER RELATIVE
Name (2): LIN, JINGHUAN
Relationship to You: CHILD
Have you ever been in the U.S.? NO
Have you ever been issued a U.S. visa? NO
Have you ever been refused a U.S. Visa, or been refused
admission to the United States, or withdrawn your application for
admission at the port of entry?
NO
Has anyone ever filed an immigrant petition on your behalf with
the United States Citizenship and Immigration Services?NO
U.S. Contact Information
Contact Person Name in the U.S.: LIU, KE
Organization Name in the U.S.: DO NOT KNOW
Relationship to You: RELATIVE
U.S. Contact Address: 408 REID STREET
LEXINGTON, VIRGINIA 24450
Phone Number: 5403190193
Email Address: liu.k@law.wlu.edu
Family Information
Father's Surnames: PIAO
Father's Given Names: DAOHAI
Father's Date of Birth: DO NOT KNOW
Is your father in the U.S.? NO
Mother's Surnames: JIN
Mother's Given Names: YUDONG
Mother's Date of Birth: DO NOT KNOW
Is your mother in the U.S.? NO
Do you have any immediate relatives, not including parents in the
U.S.? NO
Do you have any other relatives in the United States?YES
Deceased Spouse's Full Name: LIN, MAOCHUN
Deceased Spouse's Date of Birth: 15 FEBRUARY 1931
Deceased Spouse's Country/Region of Origin (Nationality):CHINA
Country/Region of Birth: CHINA
Work/Education/Training Information
Primary Occupation: HOMEMAKER
Were you previously employed? NO
Have you attended any educational institutions at a secondary
level or above? NO
Do you belong to a clan or tribe? NO
Provide a List of Languages You Speak:
Language Name: (1): KOREAN
Language Name: (2): CHINESE
Have you traveled to any countries within the last five years?YES
Country/Region Visited (1): KOREA, REPUBLIC OF
(SOUTH)
Have you belonged to, contributed to, or worked for any
professional, social, or charitable organization? NO
Do you have any specialized skills or training, including firearms,
explosives, nuclear, biological, or chemical experience?NO
Have you ever served in the military? NO
Have you ever served in, been a member of, or been involved
with a paramilitary unit, vigilante unit, rebel group, guerrilla group,
or insurgent organization?
NO
Security and Background Information
Do you have a communicable disease of public health
significance? (Communicable diseases of public significance
include chancroid, gonorrhea, granuloma inguinale, infectious
leprosy, lymphogranuloma venereum, infectious stage syphilis,
active tuberculosis, and others diseases as determined by the
Department of Health and Human Services.)
NO
Do you have a mental or physical disorder that poses or is likely
to pose a threat to the safety or welfare of yourself or others?NO
Are you or have you ever been a drug abuser or addict?NO
Have you ever been arrested or convicted for any offense or
crime, even though subject of a pardon, amnesty, or other similar
action?
NO
Have you ever violated, or engaged in a conspiracy to violate,
any law relating to controlled substances? NO
Are you coming to the United States to engage in prostitution or
unlawful commercialized vice or have you been engaged in
prostitution or procuring prostitutes within the past 10 years?
NO
Have you ever been involved in, or do you seek to engage in,
money laundering? NO
Have you ever committed or conspired to commit a human
trafficking offense in the United States or outside the United
States?
NO
Are you the spouse, son, or daughter of an individual who has
committed or conspired to commit a human trafficking offense in
the United States or outside the United States and have you
within the last five years, knowingly benefited from the trafficking
activities?
NO
Have you knowingly aided, abetted, assisted or colluded with an
individual who has committed or conspired to commit a severe
human trafficking offense in the United States or outside the
United States?
NO
Do you seek to engage in espionage, sabotage, export control
violations, or any other illegal activity while in the United States?NO
Do you seek to engage in terrorist activities while in the United
States or have you ever engaged in terrorist activities?NO
Have you ever or do you intend to provide financial assistance or
other support to terrorists or terrorist organizations?NO
Are you a member or representative of a terrorist organization?NO
Have you ever ordered, incited, committed, assisted, or otherwise
participated in genocide? NO
Have you ever committed, ordered, incited, assisted, or otherwise
participated in torture? NO
Have you committed, ordered, incited, assisted, or otherwise
participated in extrajudicial killings, political killings, or other acts
of violence?
NO
Have you ever engaged in the recruitment or the use of the child
soldiers? NO
Have you, while serving as a government official, been
responsible for or directly carried out, at any time, particularly
severe violations of religious freedom?
NO
Have you ever been directly involved in the establishment or
enforcement of the population controls forcing a woman to
undergo an abortion against her free choice or a man or a woman
to undergo sterilization against his or her free will?
NO
Have you ever been directly involved in the coercive
transplantation of human organs or bodily tissue? NO
Have you ever sought to obtain or assist others to obtain a visa,
entry into the United States, or any other United States
immigration benefit by fraud or willful misrepresentation or other
unlawful means?
NO
Have you ever withheld custody of a U.S. citizen child outside the
United States from a person granted legal custody by a U.S.
court?
NO
Have you voted in the United States in violation of any law or
regulation? NO
Have you ever renounced United States citizenship for the
purpose of avoiding taxation? NO
Location Information
Location where you will be submitting your application
Current Location: GUANGZHOU, CHINA
Preparer of Application
Did anyone assist you in filling out this application?YES
Preparer Surnames: HUANG
Preparer Given Names: HAIYUAN
Organization Name: DOES NOT APPLY
Street Address: 23-150-4A WUYIHUAYUAN
TONGZHOU DIST
City: BEIJING
State/Province: DOES NOT APPLY
Postal Zone/ZIP Code: 101100
Country/Region: CHINA
Relationship to You: SON-IN-LAW